Multiple nerve blocks may be painful and a source of discomfort. We assessed the efficacy of sufentanil 5 &mgr;g combined with midazolam 1 mg in decreasing pain in outpatients after a midhumeral multiple nerve stimulation technique. Visual analog scores for pain were significantly lower in those patients who received sedation before the block, both at the time of block performance (14 ± 1 vs 27 ± 2 mm, P < 0.0001) and at discharge (11 ± 1 vs 24 ± 2 mm, P < 0.0001). We conclude that the association of sufentanil and midazolam produced minimal sedation while significantly reducing pain experienced by patients undergoing multiple nerve stimulation. Implications In a prospective trial of 168 patients, the use of sedation significantly reduced pain during a multiple-nerve stimulation block. The combination of sufentanil and midazolam produced either minimal or no sedation and allowed the performance of the block in awake and cooperative patients. Light sedation may improve patient acceptance of this technique

To date, results of studies evaluating the efficacy of opioids and local anesthetic combinations in the brachial plexus are inconclusive. We examined whether increasing sufentanil in doses of 5, 10, and 20 &mgr;g decreased onset time or increased duration of an axillary brachial plexus block. Ninety-two patients scheduled for carpal tunnel release under axillary brachial plexus block were enrolled in the study. Patients were randomized to receive axillary plexus block with 40 mL 1.5% mepivacaine and saline (Group 1), sufentanil 5 &mgr;g (Group 2), 10 &mgr;g (Group 3), or 20 &mgr;g (Group 4). Onset and duration of sensory and motor block were measured. Opioid-related side effects were recorded. The addition of sufentanil did not improve speed of onset or increase the duration of sensory or motor block. Paradoxically, duration of sensory and motor block was longest in the control group: sensory, 241 min (188–284) and motor, 234 min (128–305), and decreased with increasing doses of sufentanil in Group 4: sensory, 216 min (115–315) and motor, 172 min (115–260) (P < 0.05). Side effects occurred in 55% of patients belonging to Groups 2 and 4, and in 60% of the patients in Group 3. In contrast, only 10% of the patients reported side effects in the control group. We conclude that sufentanil added to mepivacaine does not increase the onset or prolong the duration of an axillary plexus block. Furthermore, the addition of sufentanil was associated with a frequent incidence of side effects. Implications This study demonstrates that the addition of sufentanil in a dose-dependent manner to 1.5% mepivacaine in the axillary plexus does not improve onset or duration of blockade, and that this admixture is associated with an increased incidence of side effects.

Background: Mechanical and/or hormonal factors may increase the spread of epidural anaesthesia in pregnancy, and hormonal changes are more pronounced in high‐order pregnancies. However, no previous study has evaluated the dose requirements and haemodynamic effects of epidural anaesthesia for caesarean delivery in this latter situation.Methods: The anaesthetic requirements to obtain a T4 upper sensory level were restrospectively compared in triple (n=19) or quadruple (n=2) pregnancies to 31 singleton pregnancies who received epidural anaesthesia for elective caesarean delivery using 2% lidocaine with 1/200 000 adrenaline.Results: In high‐order pregnancies, the gestational age at delivery was lower than in singleton pregnancies (34.9±1.9 weeks vs 38.2±1.1 weeks; P=0.0001) whereas maternal body weight (76.5±8.7 kg vs 73.4±14.8 kg; NS) and lidocaine requirements (428±95 mg vs 426±98 mg; NS) were similar. Moreover, although the overall incidence of hypotension was not different (multiple pregnancy; 65% vs 58% in singletons), ephedrine (5.4±5.3 mg vs 10.7±13.8 mg; P<0.05) and additional fluid requirements during onset of the block (4.3±1.7 mL/kg vs 5.3±2.6 mL/kg; P=0.03) were less than in singletons.Conclusion: We found surprisingly similar anaesthetic requirements for epidural anaesthesia in high‐order and singleton pregnancies. Mechanical factors may have played an important role. Moreover, the need for ephedrine and fluids was less in high‐order pregnancies. This could be related to more pronounced physiological changes or to different physician attitudes.

We report a case of Streptococcus salivarius meningitis following combined spinal–epidural analgesia for labour. Although rare, bacterial meningitis following combined spinal–epidural anaesthesia is being increasingly described. We review the previously reported cases and discuss the possible aetiological causes and the aseptic precautions likely to reduce the incidence of infectious complications.

Objective: To evaluate the learning of tracheal intubation with a new rigid fibreoptic laryngoscope (UpsherScope(TM)).Study design: Open prospective study.Patients: Five investigators used the UpsherScope(TM) to intubate the trachea in 164 patients scheduled for gynaecological surgery requiring tracheal intubation. All patients were of physical class ASA I or II and criteria for difficult intubation were negative.Methods: After muscle relaxation, 120 seconds were allowed to intubate the trachea with the UpsherScope(TM). If intubation had not been achieved by that time, the attempt was considered as a failure and the trachea was intubated using conventional laryngoscopy.Results: The overall success rate with the UpsherScope(TM) was 73%. Forty-five tracheas could not be intubated with the device within 120 seconds. The inability to insert the tracheal tube through the vocal cords despite a good view of the larynx (23/45) or the inability to visualise the glottis because of secretions (21/45), were the two main causes of failure.Conclusion: The UpsherScope(TM), a new rigid fibreoptic laryngoscope devised for routine and difficult intubation, is robust and allows the view of the tracheal tube passing between the vocal cords. However, in this study the intubation success rate remained low and was not improved by further experience. No benefit was found with the UpsherScopeTM in patients with normal airways. Further studies are necessary to assess its efficiency in cases of difficult intubation. (C) 1998 Elsevier, Paris.

Although hypothermia has been reported during epidural anesthesia performed for nonobstetrical surgery or cesarean section, epidural analgesia for labor may lead to hyperthermia. Its incidence, time-course and intensity are influenced by multiple factors including site of measurement, duration of labor preceding epidural analgesia and perhaps ambient temperature and occurrence of shivering. During the first 2-5 h of epidural analgesia, a significant increase in temperature is not usually observed. Then, if labor is prolonged (mostly in primiparas), temperature may increase at a rate of 0.07-0.15 degrees C per hour. Imbalance between reduced heat loss during epidural analgesia and labor-induced heat production has been implicated but impairment of central temperature regulation cannot be excluded. This hyperthermia is usually of mild intensity (< 38 degrees C) and occurs in the absence of any infectious process; maternal and fetal consequences are also usually absent and treatment is probably unnecessary. However, fetal tachycardia may occur and the potential for a deleterious effect on the fetus remains controversial. Various measures for cooling the mother have been proposed but their efficacy has not been evaluated. The recognition that epidural analgesia may provoke hyperthermia may help to avoid inappropriate use of antibiotics or fetal extraction.